CARDIOVASCULAR DISORDERS

ANATOMY & PHYSIOLOGY REVIEW & ASSESSMENT

ANATOMY & PHYSIOLOGY REVIEW

•Heart - hallow muscular organ located in the center of thorax, where it

occupies a space between the lungs (mediastinum) and rest on the
diaphragm
•Lies beneath the sternum in the mediastinum between the second and sixth
rib; behind the breast bone
•Heart pumps blood to the tissues, supplying them with oxygen and other
nutrients

•Systole - contraction of the muscle - chambers become smaller as the

blood is ejected
•Diastole - relaxation of the muscle, chambers fill with blood in preparation
for ejection

HEART
•Three Layers
•Endocardium - thin inner layer, endothelium, lines inside of heart and
vessels
•Myocardium - middle muscle layer, striated muscle fibers, thickest, cause
heart to contract or responsible for pumping action
•Epicardium - exterior layer, fibrous outer layer
•Heart incased (or surrounded by ) a thin fibrous sac - pericardium
HEART CHAMBERS
•Four chambered pump (Right and left sided pumping systems)
•Right side of heart, right atrium and right ventricle - distributes venous
blood (deoxygenated) to the lungs via the pulmonary artery (pulmonary
circulation) for oxygenation
•Left side of heat, left atrium and left ventricle - distributes oxygenated blood
to the remainder of the body via aorta (systemic circulation)
•See figure 31-2, pg 757

HEART POSITION
•Heart lies in a rotated position within chest cavity
•Right ventricle lies anteriorly (just beneath sternum)
•Left ventricle situated posteriorly
•Apex (pointed end of heart) beat or point of maximum impulse (PMI)
normally palpable in the left midclavicular line of chest wall @ 5th intercostal
space
•Four surfaces of heart – anterior, posterior, inferior, lateral
 HEART VALVES
•Allow blood to flow in forward direction
•Atreoventicular valves (valves that separate the atria from the ventricles)
•Tricuspid
•Mitral (bicuspid)
•Semilunar
•Pulmonic
•Aortic
BLOOD FLOW THROUGH THE HEART
•Inferior & Superior vena cava
•Right atrium
•Tricuspid valve
•Right ventricle
•Pulmonary artery
•Lungs
•Pulmonary vein
•Left atrium
•Bicuspid valve (mitral)
•Left ventricle
•Aortic semilunar valve
•Aorta
BLOOD SUPPLY OF MYOCARDIUM
•The main coronary arteries extend over the surface of the heart and
surround it like a crown
•From these arteries that heart receives all of blood supply
•Right coronary artery and branches supplies right atrium, right ventricle, &
portion of posterior wall of Left ventricle
•Left coronary artery & branches (left anterior descending artery & left
circumflex artery supplies left atrium & left ventricle
•Heart has large metabolic requirement (70-80% oxygen)
•Blood flow into the coronary arteries occurs during diastole (rest) unlike
other arteries

•Left coronary artery - three branches

•Left main coronary artery
•Left anterior descending artery
•Circumflex artery
•Right coronary artery (supply right side of heart)
•Posterior descending artery supplies posterior wall of heart
•Divisions of coronary veins parallel the coronary arteries
•Blood from coronary system drains into coronary sinus – empties into right
atrium near entrance of inferior vena cava

CORONARY CIRCULATION
 CONDUCTION SYTEM
•Specialized heart cells of the cardiac conduction system methodically
generate and coordinate the transmission of electrical impulses to the
myocardial cells - known as action potential
•Sinoatrial (SA) node - primary pacemaker of the heart - 60-100 bpm
(initiated by the SA node
•Atrioventricular (AV) node - 40-60- bpm
•Bundle of His
•Right bundle branch (right ventricle)
•Left bundle branch (left ventricle)
•Purkinje fibers - terminal point of conduction system - point at which
myocardium is stimulated causing ventricular contraction - 20-40 bpm

CARDIAC CONDUCTION
•Cardiac electrical activity is the result of the movement of ions (charged
particles such as sodium, potassium, and calcium) across the cell membrane
•Electrical changes recorded within a single cell result in whats known as the
cardiac action potential
•The ECG (electrocardiogram) is a graphic recording of the electrical current
produced by depolarization and repolarization of the heart

REGULATION OF C V SYSTEM AUTONOMIC NERVOUS SYSTEM

•Sympathetic Nervous System stimulation of heart
•Increase the heart rate
•Increase speed of impulse conduction through AV-node
•Increase force of atrial and ventricle contraction
•Affect mediated by β-adrenergic- receptors (receptors for
norepinephrine & epinephrine)
•Parasympathetic - vagus nerve
•Decrease heart rate - action on SA node
•Slows conduction through AV node
•Blood Vessels
•α-adrenergic receptors located in vascular smooth muscle cells
•Stimulation result in vasoconstriction
•Decrease stimulation - vasodilatation
•Baroreceptors - aortic arch & carotid sinus - sensitive to stretch and pressure
•Decrease heart rate (HR)
•Peripheral vasodilation

GERONTOLOGICAL CONSIDERATIONS
•Collagen & Elastin decreases
•CV response to exercise
•Cardiac valves
•Pacemaker cells
•Left bundle branch
•ECG changes
•Β-adrenergic receptors
•Arterial blood vessels
•Pulse Pressure
•Chest landmarks
ASSESSMENT OF CV SYSTEM
•Subjective Data
•CC
•Past HX
•Meds
•Surgery
•Physical Exam (Objective Data)
•General appearance
•Vital Signs
•Peripheral Vascular System
•Palpation
•Auscultation
•Table 31-5, pg 765
•Thorax
•Inspection & palpation
•Epigastric area

•Precordium
•Percussion
•Auscultation (Normal & abnormal heart sounds)
•Murmur
DIAGNOSTIC STUDIES
•Refer to table 31-7, pg 768-771
•Chest X-ray
•Electrocardiography (ECG, EKG)
•12-lead
•3-lead
•5-lead

CARDIAC CONDUCTION
•P wave
•PR interval
•QRS complex
•T wave
NORMAL ECG PATTERN
•P-wave - represents depolarization (contraction) of the atria. Produced as
impulse travels from SA & AV junction, causes atrial contraction (0.06-0.12
sec)
sec)
•P-R interval - measure of time required for impulse to spread from SA node
to the ventricle (0.12-0.20 sec)
•QRS Complex - indicates depolarization of the ventricles; conduction of
impulse through Bundle of His to Perkinge fibers causing contraction of
ventricles (0.04-0.12 sec)
•ST segment – begins at the end of S waves and ends at the beginning of
the T wave. Changes significant
•T wave - represents repolarization (rest) of the ventricles; electrical
recovery of the ventricles (0.16 sec)
•U wave - if present indicates hypokalemia or repolarization abnormalities

STEPS FOR INTERPRETATION

•P wave
•Determine rate
•Determine rhythm
•Calculate duration of PR interval
•Relationship of P to QRS
•QRS measurement and configuration
ARRHYTHMIAS
•Normal Sinus Rhythm (NSR)
•60-100 beats/min & regular
 •Normal P wave, PR interval (.12 -.20), & QRS complex ( .04-.12)
•Sinus Bradycardia (SB)
•Sinus tachycardia (ST)
•Sinus Arrhythmia
•45-100/bpm
•Normal P wave, Normal QRS, Normal conduction, Rhythm- irregular

TELEMETRY
•Transmission of raiowaves from a battery-operated transnutter worn by
patient to central bank of monitors
•Wireless
•Know guidelines for electrode placement ( Prepare pt’s skin)
•Skin clean & dry; no oil
•Rub site briskly with alcohol pad then with 2x2 gauze
•Lead wire connections intact
•Leads adequate gel (not dry)
•Decrease artifact – firmly placed, no muscle activity or electrical
interference
•Placement – West Baton Rouge (White, Black, Red)
•Connect leads to cable & monitor

DIAGNOSTIC STUDIES
•HOLTER MONITOR
•ECG rhythm recording for 24-48 hours
•Nursing Responsibilities
•See pg 768
•Cardiac Stress Test (Exercise treadmill test)
•Noninvasive
•Treadmill
•Nursing Interventions
•Thallium stress test
•Adenosine stress test

DIAGNOSTIC STUDIES
•Echocardiography
•Noninvasive ultrasound
•Transesophageal Echocardiography (TEE)
•Nuclear Cardiology
•SPECT
•PET Scan
•MRI
•MRA – Magnetic resonance angiography – used for imaging vascular
occlusive disease & abdominal aortic aneurysms
•CT Scan
 CARDIAC CATHERIZATION
•Invasive
•Fluoroscopy
•Used to diagnose CAD, coronary artery patency & extent of atherosclerosis
(% of blockage)
•Results determine if revascularization (PTCA, CABG) is necessary
Nursing Interventions
•Nursing Interventions Pre- cath - NPO after midnight;inform patient it will
involve lying on a hard table for less than 2 hours; mild sedative or moderate
sedatives given IV; experience certain sensations during the cath;(knowing
what to expect will help them to cope with the experience); may experience
flushed feeling throughout body; informed consent; assess for allergies to
shellfish, iodine or contrast medium; DC anticoagulants as ordered reduce
risk from bleeding; document presence of peripheral pulses, note intensity,
mark pulses

Nursing Interventions
•Post cath -Monitor vital signs & observe catheter access site for bleeding,
oozing, redness, swelling or hematoma formation; access peripheral pulses
in the affected extremity every 15 mins X 4, then Q 30 min X2 then Q 1 hour
X 2, then routine Q 4 hrs ; evaluate temp and color of affected extremity and
any c/o pain, numbness,tingling; observe for cardiac dysrhythmias by
observing cardiac monitor & accessing apical and peripheral pulses for
changes in rate and rhythm
•Vasovagal reaction (bradycardia, hypotension, nausea) can be precipitated
by distended bladder or by discomfort during removal of the arterial
catheter- prompt intervention required, includes raising the feet and legs
above the head , administer IV fluids and administer IV atropine; bedrest for
2-6 hours with affected leg straight and the head elevated 30 degrees
•Analgesic medications administered as prescribed for discomfort
•Instruct pt to report chest pain and bleeding or sudden discomfort from
insertion sites immediately
•Encourage fluids (PO & IV fluids as ordered) to increase urinary output to
flush out dye
•Ensure safety by instructing pt to ask for help when getting out of bed the
first time after procedure because orthostatic hypotension may occur & may
feel lightheaded and dizzy

CORONARY ANGIOGRAPHY
•Performed as part of cardiac catherization by placing special catheters
directly into coronary arteries and injecting dye
•Evaluate patency of coronary arteries & collateral circulation
•Nursing Responsibilities

LABS & SERUM CARDIAC MARKERS

•RBC & Hgb
•Clotting Times – PT & INR & PTT
•Creatinine Kinase (CK)
•CK –MM
•CK – BB
•CK – MB – specific for myocardial tissue injury
•Cardiac Troponin
•Troponin T (cTnT)
•Troponin I (cTnI)
•Myoglobin
OTHER LABS
•Homocysteine

•C-Reactive Protein (CRP)

•B-type Natriuretic Peptide (BNP)

ROLE OF CHOLESTEROL AND LIPOPROTEINS

•Cholesterol is a waxy substance produced by the liver. Helps body heal
itself
•Also found in certain foods ( meats, eggs, and diary products)
•Triglycerides - body can’t use all the fats & carbohydrates - stores some as
triglycerides
•Too much cholesterol in the blood causes plaque formation in the arteries;
which results in narrowing or blockage in the arteries that can lead to heart
attack or stroke

LIPID PROFILE (STUDIES)

•Blood lipids consist of
•Triglycerides
•Cholesterol
•Phospholipids
•Circulate in blood bound to proteins - called lipoproteins
TRIGLYCERIDES
•Main storage form of lipids, consist of 95% of fatty tissue, source for energy
•Elevations associated with cardiovascular disease
•Requires fasting state - 12 hours except for water; not alcohol 24 hours
before
•Values age and sex related - 40-190 mg/dl
TOTAL CHOLESTEROL
•Blood lipid necessary for production of steroids, sex hormones, bile acids &
cellular membrane
•Absorbed from food & GI tract; also synthesized in liver
•Increased cholesterol - risk for atherosclerotic heart disease
•Measured anytime of day - nonfasting
•< 200 mg/dl
LIPOPROTEINS
•Low-density lipoprotein (LDL) “bad” cholesterol because it carries
cholesterol to the tissues of the body, including the arteries
•High-density lipoprotein (HDL) “good “ cholesterol because it helps to keep
cholesterol from building up in the arteries
•Very-low-density lipoprotein (VLDL) contain triglycerides; high levels
considered a risk factor for developing CVD

•GOOD CHOLESTEROL
•HDL - carries off cholesterol - believed purpose is to remove cholesterol
form peripheral tissues & transport to liver for excretion
•Inversely related to risk for CAD - Higher HDL levels lower incidence
of CAD
•Males - > 45 mg/dl (37-70 mg/dl)
•Females - > 55 mg/dl (40-88 mg/dl)
•NOT GOOD - BAD CHOLESTEROL
•LDL - cholesterol rich , tend to be deposited in peripheral tissues & blood
vessels
•Higher LDL - higher incidence of CAD
•60 - 180 mg/dl (< 130 mg/dl)
•Fasting required - 12-18 hours before blood drawn